Provider Demographics
NPI:1023760626
Name:ODOM, EDITH HOLLIE
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:HOLLIE
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 LANSFORD PL # 100
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6979
Mailing Address - Country:US
Mailing Address - Phone:843-293-8850
Mailing Address - Fax:843-293-8860
Practice Address - Street 1:106 LANSFORD PL # 100
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6979
Practice Address - Country:US
Practice Address - Phone:843-293-8850
Practice Address - Fax:843-293-8860
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily